| Entity Name: | THE FLORIDA PAIN MANAGEMENT CENTER, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Inactive |
| Date Filed: | 04 Jun 1987 (38 years ago) |
| Date of dissolution: | 27 Sep 2024 (4 months ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2024 (4 months ago) |
| Document Number: | J75833 |
| FEI/EIN Number | 59-3006597 |
| Address: | 111 WATERMAN AVENUE, MT. DORA, FL 32757 |
| Mail Address: | 111 WATERMAN AVENUE, MT. DORA, FL 32757 |
| ZIP code: | 32757 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1811967250 | 2006-01-26 | 2013-12-13 | 111 WATERMAN AVE, MOUNT DORA, FL, 327579541, US | 111 WATERMAN AVE, MOUNT DORA, FL, 327579541, US | |||||||||||||||||||||||||||||||||
|
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| Phone | +1 352-735-3313 |
| Fax | 3527353711 |
Authorized person
| Name | STACY J. BERCKES |
| Role | PRESIDENT |
| Phone | 3527353313 |
Taxonomy
| Taxonomy Code | 207L00000X - Anesthesiology Physician |
| Is Primary | No |
| Taxonomy Code | 207LP2900X - Pain Medicine (Anesthesiology) Physician |
| Is Primary | Yes |
| Taxonomy Code | 208VP0000X - Pain Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 208VP0014X - Interventional Pain Medicine Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 0053506100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BURTON BUSH, RICHARD | Agent | 3375 Capital Cir NE, SUITE 300, Bldg C200, TALLAHASSEE, FL 32308-3778 |
| Name | Role | Address |
|---|---|---|
| BERCKES, STACY J. | Secretary | 38440 TIMBERLANE DRIVE, UMATILLA, FL |
| Name | Role | Address |
|---|---|---|
| BERCKES, STACY J. | President | 38440 TIMBERLANE DRIVE, UMATILLA, FL |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2024-09-27 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-01-21 | 3375 Capital Cir NE, SUITE 300, Bldg C200, TALLAHASSEE, FL 32308-3778 | No data |
| REGISTERED AGENT NAME CHANGED | 2003-01-22 | BURTON BUSH, RICHARD | No data |
| CHANGE OF PRINCIPAL ADDRESS | 1994-12-05 | 111 WATERMAN AVENUE, MT. DORA, FL 32757 | No data |
| CHANGE OF MAILING ADDRESS | 1994-12-05 | 111 WATERMAN AVENUE, MT. DORA, FL 32757 | No data |
| CORPORATE MERGER | 1993-06-15 | No data | CORPORATION WAS A MERGER RESULT. TOTAL NUMBER OF QUALIFIED CORPORATION(S) INVOLVED WAS 1. CORPORATE MERGER NUMBER 900000001449 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2023-01-26 |
| ANNUAL REPORT | 2022-01-21 |
| ANNUAL REPORT | 2021-01-11 |
| ANNUAL REPORT | 2020-01-15 |
| ANNUAL REPORT | 2019-01-29 |
| ANNUAL REPORT | 2018-01-17 |
| ANNUAL REPORT | 2017-01-09 |
| ANNUAL REPORT | 2016-01-27 |
| ANNUAL REPORT | 2015-01-16 |
| ANNUAL REPORT | 2014-02-01 |
Date of last update: 04 Feb 2025
Sources: Florida Department of State
